David Sumner is not a name you’d normally see associated with EHRs, HIPAA or anything else to do with medical health technology. However, Sumner the CEO of the American Radio Relay League (ARRL) – the main US ham radio association – just made an important point that effects HIE, EHRs and medical health technology. Why did he venture into alien territory? He was concerned that HIPAA’s privacy requirements could severely limit hams emergency operations.

When it comes to emergencies, main communications systems often go down. Amateurs are often the only communications available. Whether it’s a hurricane, tornado, tsunami or earthquake these volunteers often react when others can’t. For example, hams have provided communications for the Boston Marathon for years. When the bombings occurred, cell systems were overwhelmed. They quickly switched from coordinating race operations to aiding relief efforts.

In an editorial in the October issue of QST, the ARRL’s magazine, Sumner noted that international agreements and federal law require amateur radio to communicate in the open and not use encryption. (Morse code, etc., are open standards and are not considered encryption.) Keeping things in the open is a guard against fraud and abuse. However, he wanted to know if this meant medically identifiable information, was an exception to the openness requirement?

In a word, no. To answer the question, he looked at HIPAA’s legislative history and the FCC’s opinion on transmitting patient information. Sumner found that HIPAA’s “regulations do not require encryption of radio transmissions of medical patient information.” (QST, October 2013, p. 9. It Seems to Us.

However, he goes on to say:

While HIPAA may not require encryption of radio transmissions, it is clear that medical care providers are very protective of patient privacy. Information identifying a patient is seldom transmitted anyway. Our served agencies may well prefer that the messages we send on their behalf not be intercepted by unknown listeners. If so there are steps, we can take such as using less-popular frequencies, directional antennas, minimum power and voice modes other than FM that will greatly reduce the likelihood of eavesdropping. (Ibid)

What this means for CIOs, emergency coordinators, etc., is that they need to discuss patient privacy, and amateur radio communications as part of their emergency planning.

[Disclosure: I hold Advanced Class amateur radio license, W3HBK, and am an ARRL member, but have no connection to Sumner or QST.]David Sumner is not a name you’d normally see associated with EHRs, HIPAA or anything else to do with medical health technology. However, Sumner the CEO of the American Radio Relay League (ARRL) – the main US ham radio association – just made an important point that effects HIE, EHRs and medical health technology. Why did he venture into alien territory? He was concerned that HIPAA’s privacy requirements could severely limit hams emergency operations.

When it comes to emergencies, main communications systems often go down. Amateurs are often the only communications available. Whether it’s a hurricane, tornado, tsunami or earthquake these volunteers often react when others can’t. For example, hams have provided communications for the Boston Marathon for years. When the bombings occurred, cell systems were overwhelmed. They quickly switched from coordinating race operations to aiding relief efforts.

In an editorial in the October issue of QST, the ARRL’s magazine, Sumner noted that international agreements and federal law require amateur radio to communicate in the open and not use encryption. (Morse code, etc., are open standards and are not considered encryption.) Keeping things in the open is a guard against fraud and abuse. However, he wanted to know if this meant medically identifiable information, was an exception to the openness requirement?

In a word, no. To answer the question, he looked at HIPAA’s legislative history and the FCC’s opinion on transmitting patient information. Sumner found that HIPAA’s “regulations do not require encryption of radio transmissions of medical patient information.” (QST, October 2013, p. 9. It Seems to Us.

However, he goes on to say:

While HIPAA may not require encryption of radio transmissions, it is clear that medical care providers are very protective of patient privacy. Information identifying a patient is seldom transmitted anyway. Our served agencies may well prefer that the messages we send on their behalf not be intercepted by unknown listeners. If so there are steps, we can take such as using less-popular frequencies, directional antennas, minimum power and voice modes other than FM that will greatly reduce the likelihood of eavesdropping. (Ibid)

What this means for CIOs, emergency coordinators, etc., is that they need to discuss patient privacy, and amateur radio communications as part of their emergency planning.

[Disclosure: I hold Advanced Class amateur radio license, W3HBK, and am an ARRL member, but have no connection to Sumner or QST.]

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[Note: These two posts are reprinted, with permission, from Dr. Robert M. Centor’s db’s Medical Rants]

The patient note is the biggest problem in medicine today

by RCENTOR on AUGUST 30, 2013

I spent yesterday at Hennepin County Hospital in Minneapolis. During lunch, we had a discussion about the thought process of internal medicine, and how we should teach thinking. Not surprisingly, attention turned to the patient note. The teachers in the audience bemoaned the degradation of the patient note.

We need a mission. We need to resuscitate the patient note. We need meaningful, readable, informative patient notes.

We need clinicians (that term used rather than physicians, because not all physicians do enough clinical work to be clinicians) to state the standards for good patient notes. We need real analyses and plans that every other physician can interpret and understand.

We do not need daily physical exams, except for the relevant systems. We do not need daily review of systems, rather just an updated history of the active problems and the answer to the open ended question about new complaints.

We should reclaim the patient note. I would prefer that we return to Larry Weed’s original SOAP notes. Each problem had a subjective, an objective, an assessment and a plan. As I wrote those notes, the pieces congealed into a larger whole. We should unite to object against notes designed for billing. And we should probably outlaw cut and paste.

The movement to improve patient notes

by RCENTOR on SEPTEMBER 3, 2013

Last week I tweeted about my recent posts on the patient note. This week I will continue trying to stimulate a movement and have bloggers and tweeters join that movement.

It is time for an “English First” movement for medical documentation. Call it “Leave No Narrative Behind” or something equally catchy. Let’s defend the medical record from the compliance officers, insurance companies, lawyers, regulators, accreditors, and EHR vendors. Let’s exile the “ten-point review of systems” to the auto repair shop!

That’s why the American College of Physicians recently approved a resolution that “endorses and actively promotes documentation within the electronic medical record (EMR) to improve communication that emphasizes the thought process underlying decision making, patient complexity, and medical necessity with clarity and without requiring repetition of past notes, tests and extraneous data.”

One of the most liberating things that I’ve done in a while is to use voice recognition software with my EHR. Instead of clicking boxes to generate a “Med Lib” supplemented by hastily typed short phrases, I now dictate a paragraph or two for the HPI, the review of systems, and the examination, and I document as thorough an assessment and plan as I did in the days that we documented in English. Someone can read my notes and know what I did, and more importantly, what I was thinking. That still doesn’t cure the systemic illness of billing needs trumping clinical needs in medical documentation. But it’s a start.

Yul has helped start the movement. Will you please blog and tweet about this movement? We have many physicians involved in social media. If social media has power, we should use that power. Or do you like the notes that you find in charts and referral letters?

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One thing that’s certain in the EHR world, someone is either polling or blogging about the results. The problem is how do you know which poll to believe and which to trash? It’s not an easy question, if for no other reason than the remarkable volume of studies.

Five Questions

To figure this out, I ask myself five questions about EHR polls. The answers help me figure out which are the real deal and which to ignore. Here my five:

What does it say? What is its take away? Not just the headline, but what do the findings reveal? A study may be rigorously done, but if the author makes an inductive leap over a cliff from results to meaning, the work is for naught.

Who’d they ask? A valid poll’s sample should be a microcosm of the whole group. The idea is that if you contacted everyone in the group you’d get the same results you got from your poll.
If the survey lets anyone answer, then it only represents those who answered. For example, let’s say in 2012 Fox News and MSNBC each ran an on line poll of Romney versus Obama. The polls let anyone vote. Would you be surprised that Romney won on Fox, but Obama won on MSNBC?

What did they ask? If I can read the questions, I look to see if they are fairly worded. I’m leery if they’re a version of the classic leading question, “How long have you been beating your wife?”

Is it free? I can understand paying for a study that’s cost a lot to produce. What I can’t understand is a study that touts its findings, but puts its methodology behind a pay wall.

Who did it? If you have questions, you should be able to contact the chief investigator.

Two EHR Poll Examples

Here are two recent studies that make important statements about the EHR field. Let’s see how they fare:

1. Accenture Survey Reveals Most US Doctors Believe Patients Should Help Update Their Electronic Health Records, But Shouldn’t Have Access to Their Full Record. URL: http://goo.gl/2ymctw.a. The Claim. This poll makes a strong statement about how US doctors view patient’s role in their medical record. It says an overwhelming number of physicians, 82 percent, want their patients to update their EHRs, but only 31 percent believe that patients should be able to see their full record. If true, this has major policy implications.b. Who Was Asked? Accenture hired Harris Interactive to administer the poll. Harris asked 3,700 physicians in eight countries. This included 500 US doctors. The poll was done on line. Any physician could participate.
The poll’s biggest problem is that it is a self selecting sample. There is no attempt to show that it is representative of US doctors as a whole, much less ambulatory, in patient, etc.c. Questions? The questions asked aren’t listed.d. Free? There is no charge for the viewing the poll. The results are posted in two .pdf pages on Accenuture’s site.e. Investigator. No contact’s given for Harris Interactive. It lists three major Accenture officials.

2.Software Advice: Four Years Later: The Impact of the HITECH Act on EHR Implementations. URL:http://goo.gl/OcIeVO.a. The Claim. Software Advice is an online technology service for those shopping for vertical software products. Their survey has these major findings:i. Replacements. 31.2 percent of EHR shoppers were looking for a replacement. It was 21.0 percent in 2010.ii. New. 16.4 percent of shoppers in 2013 were opening a new practice versus 12.2 in 2010.iii. Paper. 50.9 percent were dropping paper systems compared to 64.9 percent in 2010.b. Who Was Asked? Software Advice (SA) polled 385 practices chosen at random from those who had contacted the firm. They were chosen from a group of likely buyers who had contacted the firm. SA is clear about who was in their full group and who they sampled. They say:i. Self-Selection Bias. Almost all of the individuals we qualified discovered our site through an Internet search and then consented to a 15-minute phone call discussing their EHR selection process. This may skew the results toward buyers who are more technologically savvy, as well as to those who are uncertain as to which product they are going to buy. Buyers who rely exclusively on referrals from colleagues to make their EHR purchase decisions, for example, were not likely to have been sampled. . . . [It also states:]Not included in this survey sample are the countless successful EHR implementations: buyers who purchased an EHR and absolutely love it; or practices for whom the savings in time and efficiency were well worth the costs of the software and the transition.c. Questions? The questions are not available.d. Free. Yes. The results are posted on its web site.e. Investigator? There are no contacts for the survey, however SA’S Larik Malish answered comments from readers.

Of these two examples, Accenture’s claims are based on a self selecting survey, which is unlikely to represent more than those who answered. I wouldn’t give its claims much weight.

SA’s study is representative within its defined limits. Within those limits, it’s worth taking into account.

Trying to make sense of EHR poll claims is not for the meek. There are polls and then there are polls. A few questions can help sort them out.

Carl BergmanManaging PartnerEHRSelector.com

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The Selector’s Blog

Choosing an EHR/EMR is a hard task. For many years, we hosted the EHRSelector, which we designed to help you pick an EHR by features. It had the most granular feature list on the web. When we were not able to entice enough vendors participation, we closed the system. However, we believe our feature list is unique and useful, so you can download it here: EHR Selector Feature List. We also will continue to write about EHR related issues.